Role of Extent of Resection in the Long-Term Outcome of Low-Grade Hemispheric Gliomas

Department of Neurological Surgery, Brain Tumor Research Center, University of California San Francisco, 505 Parnassus Ave, Room M-779, San Francisco, CA 94143-0112, USA.
Journal of Clinical Oncology (Impact Factor: 18.43). 04/2008; 26(8):1338-45. DOI: 10.1200/JCO.2007.13.9337
Source: PubMed


The prognostic role of extent of resection (EOR) of low-grade gliomas (LGGs) is a major controversy. We designed a retrospective study to assess the influence of EOR on long-term outcomes of LGGs.
The study population (N = 216) included adults undergoing initial resection of hemispheric LGG. Region-of-interest analysis was performed to measure tumor volumes based on fluid-attenuated inversion-recovery (FLAIR) imaging.
Median preoperative and postoperative tumor volumes and EOR were 36.6 cm(3) (range, 0.7 to 246.1 cm(3)), 3.7 cm(3) (range, 0 to 197.8 cm(3)) and 88.0% (range, 5% to 100%), respectively. There was no operative mortality. New postoperative deficits were noted in 36 patients (17%); however, all but four had complete recovery. There were 34 deaths (16%; median follow-up, 4.4 years). Progression and malignant progression were identified in 95 (44%) and 44 (20%) cases, respectively. Patients with at least 90% EOR had 5- and 8-year overall survival (OS) rates of 97% and 91%, respectively, whereas patients with less than 90% EOR had 5- and 8-year OS rates of 76% and 60%, respectively. After adjusting each measure of tumor burden for age, Karnofsky performance score (KPS), tumor location, and tumor subtype, OS was predicted by EOR (hazard ratio [HR] = 0.972; 95% CI, 0.960 to 0.983; P < .001), log preoperative tumor volume (HR = 4.442; 95% CI, 1.601 to 12.320; P = .004), and postoperative tumor volume (HR = 1.010; 95% CI, 1.001 to 1.019; P = .03), progression-free survival was predicted by log preoperative tumor volume (HR = 2.711; 95% CI, 1.590 to 4.623; P <or= .001) and postoperative tumor volume (HR = 1.007; 95% CI, 1.001 to 1.014; P = .035), and malignant progression-free survival was predicted by EOR (HR = 0.983; 95% CI, 0.972 to 0.995; P = .005) and log preoperative tumor volume (HR = 3.826; 95% CI, 1.632 to 8.969; P = .002).
Improved outcome among adult patients with hemispheric LGG is predicted by greater EOR.

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    • "We hope this will make image interpretation easier at the end of a brain tumor resection, an improvement that could be of particular importance for users with limited experience in using ultrasound guided surgery. Improved imaging near the end of the surgery could be associated with improved resection grades that again improves clinical outcome [2,4,5,16]. We now hope to translate these positive findings from simulation and the animal models to highly selected patients with suspected high-grade glioma to further evaluate the potential benefits while carefully monitor any potential adverse events. "
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    ABSTRACT: Use of ultrasound in brain tumor surgery is common. The difference in attenuation between brain and isotonic saline may cause artifacts that degrade the ultrasound images, potentially affecting resection grades and safety. Our research group has developed an acoustic coupling fluid that attenuates ultrasound energy like the normal brain. We aimed to test in animals if the newly developed acoustic coupling fluid may have harmful effects. Eight rats were included for intraparenchymal injection into the brain, and if no adverse reactions were detected, 6 pigs were to be included with injection of the coupling fluid into the subarachnoid space. Animal behavior, EEG registrations, histopathology and immunohistochemistry were used in assessment. In total, 14 animals were included, 8 rats and 6 pigs. We did not detect any clinical adverse effects, seizure activity on EEG or histopathological signs of tissue damage. The novel acoustic coupling fluid intended for brain tumor surgery appears safe in rats and pigs under the tested circumstances.
    BMC Medical Imaging 03/2014; 14(1):11. DOI:10.1186/1471-2342-14-11 · 1.31 Impact Factor
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    • "A significant survival benefit 58 was demonstrated if treated at a centre favoring early surgical 59 resection as opposed to biopsy and watchful waiting. Most authors 60 now argue in favor of early resections [2] [3] [4] [5]. However, the balanc- 61 ing act between improving survival by extensive resections and 62 inducing deficits is delicate. "
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    ABSTRACT: Reports on long-term health related quality of life (HRQL) after surgery for World Health Organization grade II diffuse low-grade gliomas (LGG) are rare. We aimed to compare long-term HRQL in two hospital cohorts with different surgical strategies. Biopsy and watchful waiting was favored in one hospital, while early resections guided with three-dimensional (3D) ultrasound was favored in the other. With a population-based approach 153 patients with histologically verified LGG treated from 1998–2009 were included. Patients still alive were contacted for HRQL assessment (n = 91) using generic (EQ-5D; EuroQol Group, Rotterdam, The Netherlands) and disease specific (EORTC QLQ-C30 and BN20; EORTC Quality of Life Department, Brussels, Belgium) questionnaires. Results on HRQL were available in 79 patients (87%), 25 from the hospital that favored biopsy and 54 from the hospital that favored early resection. Among living patients there was no difference in EQ-5D index scores (p = 0.426). When imputing scores defined as death (zero) in patients dead at follow-up, a clinically relevant difference in EQ-5D score was observed in favor of early resections (p = 0.022, mean difference 0.16, 95% confidence interval 0.02–0.29). In EORTC questionnaires pain, depression and concern about disruption in family life were more common with a strategy of initial biopsy only (p = 0.043, p = 0.032 and p = 0.045 respectively). In long-term survivors an aggressive surgical approach using intraoperative 3D ultrasound image guidance in LGG does not lower HRQL compared to a more conservative surgical approach. This finding further weakens a possible role for watchful waiting in LGG.
    Journal of Clinical Neuroscience 02/2014; 21(8). DOI:10.1016/j.jocn.2013.11.027 · 1.38 Impact Factor
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    • "Resection was extended up to functional boundaries assessed by stimulation mapping that respected both eloquent cortical areas and essential subcortical pathways. This approach limits neurologic deficits while maximizing the extent of resection which is thought to have a positive impact on the further course of LGG [Smith et al., 2008; Soffietti et al., 2010]. The neurologic status was assessed immediately after surgery and again after 3 months analogical to the preoperative assessment. "
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    ABSTRACT: Objectives: Recent anatomical-functional studies have transformed our understanding of cerebral motor control away from a hierarchical structure and toward parallel and interconnected specialized circuits. Subcortical electrical stimulation during awake surgery provides a unique opportunity to identify white matter tracts involved in motor control. For the first time, this study reports the findings on motor modulatory responses evoked by subcortical stimulation and investigates the cortico-subcortical connectivity of cerebral motor control. Experimental design: Twenty-one selected patients were operated while awake for frontal, insular, and parietal diffuse low-grade gliomas. Subcortical electrostimulation mapping was used to search for interference with voluntary movements. The corresponding stimulation sites were localized on brain schemas using the anterior and posterior commissures method. Principal observations: Subcortical negative motor responses were evoked in 20/21 patients, whereas acceleration of voluntary movements and positive motor responses were observed in three and five patients, respectively. The majority of the stimulation sites were detected rostral of the corticospinal tract near the vertical anterior-commissural line, and additional sites were seen in the frontal and parietal white matter. Conclusions: The diverse interferences with motor function resulting in inhibition and acceleration imply a modulatory influence of the detected fiber network. The subcortical stimulation sites were distributed veil-like, anterior to the primary motor fibers, suggesting descending pathways originating from premotor areas known for negative motor response characteristics. Further stimulation sites in the parietal white matter as well as in the anterior arm of the internal capsule indicate a large-scale fronto-parietal motor control network.
    Human Brain Mapping 11/2013; 34(11). DOI:10.1002/hbm.22122 · 5.97 Impact Factor
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